November 10-15

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ACR Convergence 2023

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Can rheumatologists mend their relationships with PBMs?


3 minutes

It’s time to reshape the relationships between rheumatologists and pharmacy benefit managers (PBMs). Many providers see PBMs playing a larger role in complicating patient treatment than in eliminating bottlenecks that can impair outcomes.

“There is a probably accurate perception that PBMs have contributed to driving up the cost of healthcare because they are generating profits for themselves, which is taking away from the rest of the healthcare economy,” said Sean Fahey, MD, a private practice rheumatologist at Piedmont HealthCare in Mooresville, NC. “PBMs are not making decisions based on good scientific evidence or treatment guidelines. They are making treatment decisions based on which product puts the most money in their pockets.”

Dr. Fahey will explore the role of PBMs in healthcare during a combined ACR/AHRP session on Reshaping the Relationship Between Physicians & PBMs from 11:00 am – 12:00 pm Sunday in Room 11 A. PBMs can have an adverse effect on patient care and outcomes as well as financial distress.

A patient may have a 20 percent copay and is responsible for paying 20 percent of the total price of an agent, he said. But the PBM receives a rebate from the manufacturer, effectively lowering the total cost. Rather than pass that savings on to the patient and the payer, the PBM pockets the rebate.

PBMs are also responsible for the institution of mandatory step therapy and fail-first formulary tiering of expensive products, particularly biologics. Even if an agent is indicated as first-line treatment, many PBM-inspired formularies require that patients endure step therapy that subjects them to inappropriate and unsuccessful treatment before they are allowed to undergo what should have been the first-line agent.

“There are documented examples of step therapy and fail-first formulary tiering where patients have been harmed because they have not been able to get access to what is clearly the appropriate medication before they first failed some other agent that the physician clearly indicated is not medically appropriate,” Dr. Fahey said. “PBMs try to dictate which medication is the preferred agent based on how much revenue it puts in their pocket, not on medical factors.”

The ultimate goal of a PBM is not to improve patient care and outcomes but to improve their own bottom line, he said. That has led to steps such as refusal to accept copay cards for expensive agents unless they are also the preferred agent, not accepting copay cards toward the annual deductible, or not accepting copay cards until the patient has met the full deductible amount.

“It is all about gearing patients to spend more of their own money and putting more money in the pockets of the PBMs,” Dr. Fahey said.

PMBs are not the only problem players in the healthcare system, he noted. Insurance companies and other payers and manufacturers create their own problems, as do providers more focused on profits than patient outcomes. But PBMs are the biggest single focus for physicians, at least in part because they refuse to disclose their financial incentives and decision-making processes.

“This is a critical issue in trying to make sure that we, as healthcare providers, have a voice in the discussion about what is best for our patients,” Dr. Fahey said. “Get involved. Make sure your state insurance commission is aware of problems you are having with access. Make sure your state association and the ACR are aware of the problems. Talk with your elected officials. Only by standing up for ourselves and our patients can we hope to stem this tide.”